management of osteomyelitis - orthopaedic

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MANAGEMENT OF DIABETIC FOOT INFECTIONS & OSTEOMYELITIS

DR. P.C. CHYE Consultant Orthopaedic Surgeon Dept. Orthopaedic Surgery & Traumatology Hospital Kuala Lumpur

DIABETES MELLITUS Global Prevalence : • 2003 : 194 million • 2010 : 252 million • 2025 : 380 million

PREVALENCE OF DM IN MALAYSIA (Population >30 years) Prevalence of Diabetes Mellitus in Malaysia 22%

3rd

Prevalence

National Health and Mortality & Morbidity Survey

14.90% 8.30%

6.30%

2.10% 0.65% 1960

1982

1986 Year

1996

2006

08

DIABETIC FOOT INFECTIONS – RISK FACTORS •  HOST DEFENSE : Neutrophil functions : chemotaxis,phagocytosis, intracellular killing  Monocyte & complement functions • PERIPHERAL VASCULAR DISEASES : in blood supply needed to heal ulcers and infection • SENSORY NEUROPATHY :  in appreciation of pain and temperature  injuries not noticed, severity underestimated • MOTOR NEUROPATHY : anatomical foot deformity  abnormal pressure points  ulceration • AUTONOMIC NEUROPATHY : sweating, dry & cracked skin  portal of bacteria entry

DIABETIC FOOT INFECTIONS - SPECTRUM • Ranges from cellulitis to infected ulcers, abscess, osteomyelitis , wet gangrenes and necrotising fasciitis

7% of Population Diabetic 15-25% Develop Foot Ulcer

40-80% Infected (or suspected) 40% Mild

30-40% Moderate

20-30% Severe

49% of diabetic patients with diabetic foot infection will develop infection in the other foot in 18 months

DIABETIC FOOT INFECTIONS – THE DEVELOPMENT • Usually precipitated by trauma • Infection may start superficially in an ulcer or crack of the skin but can rapidly progress to involve deeper structures including tendons and bones • The anatomical structures of various compartments of the foot, tendon sheaths, ligaments, fascia and neurovascular bundles tends to facilitate proximal spread of the infection • Inflammation and infection in the foot compartments can cause compartment syndrome – vascular thrombosis

DIABETIC FOOT INFECTIONS - PRESENTATIONS • Redness, swelling, discharging sinus/ulcer, gangrene, pain • Diabetic patient may or may not mount a fever, even in the presence of severe infection • 50% of patients with a limb-threatening infection do not manifest systemic signs or symptoms leading to underestimation of the presence and severity of infection • The signs and symptoms are masked by neuropathy • Hypotension, tachycardia and severe unexplained hyperglycaemia are however often noted

DIABETIC FOOT INFECTIONS - PROGRESSION • Coexisting metabolic derangements, peripheral arterial disease, poor immune response  poor delivery of antibiotics to the infected tissues, reduced access & functions of phagocytic cells to the infected area  rapid progression of infection in hours or days & quickly become limb- or life-threatening

DIABETIC FOOT INFECTIONS • These wounds are usually more severe & more complicated to treat than do equivalent infections in persons without diabetes

DIABETIC FOOT INFECTIONS - BACTERIA INVOLVED • Aerobic Gram +ve cocci, esp (Staphylococcus aureus) are the predominant pathogens • In chronic ulcers or in patients who have recently received antibiotic therapy may be infected with Gram –ve rods • In those with foot ischaemia and gangrene may have obligate anaerobic organisms

- Staphylococcus aureus - Streptococcus sp. - Enterococcus sp. - Staphylococcus epidermidis

45% 35% 29% 23%

- Proteus mirabilis - Pseudomonas aeruginosa

26% 16%

- Peptostreptococcus sp. - Diphtheroids - Bacteroides sp.

22% 19% 16%

Microbial complexity

Limb-threatening infections are often polymicrobial

Microbial burden Clinical risk

Anaerobes

Aerobic Gram-negative rods

Gram positive cocci

Severity

1

2

3

4

Depth Necrosis Prior Rx

MULTIRESISTANT BACTERIAL INFECTIONS Diabet Met 2004 Jul;21(7) : 710-5 Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact. Hartemann-Heurtier A, Robert J, Jacqueminet S, Ha Van G, Golmard JL, Jarlier V, Grimaldi A.

• Detected in 1/3 of patients with previous history of hospital admission for the same wound • Detected in 25% of patients with osteomyelitis

Clinical Microbiology & Infection- October 2005

Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers • ALMOST 50% of Staph aureus isolated are MRSA !

TIMELINE OF STAPHYLOCOCCAL RESISTANCE Penicillin-resistance Sporadic MRSA

Epidemic MRSA GISA CA-MRSA VRSA

1940

1950

1960

1970

1980

1990

2000 2010

DIABETIC FOOT INFECTIONS – TREATMENT STRTEGIES

Require attention to both local & systemic issues

LOCAL ISSUES

DIABETIC FOOT INFECTIONS COMPREHENSIVE MANAGEMENT TREAT THE ULCER & INFECTION, GET THE WOUND TO HEAL, PREVENT RECURRENCE

SYSTEMIC ISSUES

+ TREAT THE DIABETES, ASSOCIATED SYSTEMIC PROBLEMS & OVERCOME THE UNDERLYING PATHOLOGY AT THE SAME TIME

DIABETIC FOOT INFECTIONS - MULTIDISCIPLINARY TEAM APPROACH Comprehensive management of these patients requires care of a finely-tuned multidisciplinary team for medical stabilization, surgical debridement, antibiotic selection, vascular reperfusion, wound care, podiatric care, orthotic care, nutrition support, rehabilitation and delayed reconstruction to achieve functional limb salvage

EVALUATION AT 3 LEVELS 1 The patient as a whole 2 The affected limb or foot 3 The infected wound To determine : - presence, type, extent and severity of infection - pathogens involved - presence of any systemic consequences of infection - contribution of vascular disease / neuropathy - altered foot biomechanics that contributes to the cause of the wound ( and thus, its ability to heal )

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS BLOOD INVESTIGATIONS : - Full blood count - Erythrocyte Sedimentation Rate (ESR) - C- Reactive Protein (CRP) - Random / Fasting Sugar Levels - Glycosylated Haemoglobin - Renal Profile - Serum Albumin

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS EXAMINE THE FOOT : - Palpation/probing for fluctuance & tunneling wounds/ ulcer (deep infection) - a clinically infected ulceration probes to bone – 89-95% osteomyelitis

- Blood supply : Dorsalis Pedis , Posterior Tibialis & Popliteal pulses. Ankle-Brachial Systolic Index ( ABSI ), Doppler, Evidence of ischaemia & gangrene - the degree of impaired limb perfusion significantly reduce the chances of wound healing, increases the overall severity of infection and risk of amputations

- Sensation --- Neuropathy – pain in an insensate foot means severe infection

- Deformities & Abnormal Pressure Points

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS

TAKE AN X-ray : - Osteomyelitis - Gas Gangrene - Presence of Foreign Body - Osseous deformities / fractures / dislocations MRI is more sensitive and specific, especially for extent of soft tissue involvement

DIABETIC FOOT INFECTIONS – INITIAL MANAGEMENT IDENTIFY THE ORGANISMS INVOLVED : - Send appropriately obtained speciments for culture before starting empirical antibiotic therapy - Soft tissue or bone speciments obtained by biopsy, curettage, or aspiration are preferable - Superficial swab cultures of infected ulcers often complicate evaluation of the infection - Definitive antibiotic therapy will be based on C&S results from intra-op cultures

DIABETIC FOOT INFECTIONS – INITIAL MANAGEMENT ANTIBIOTIC SELECTION Characteristic odours or history of resistant bacterial infections – affect initial antibiotic choices

Initial treatment in a previously untreated patient with a non-limb-threatening infection is focused on Staphylococcus and Streptococcus sp

Initial treatment of limbthreatening infections requires broad-spectrum antibiotics covering Staph aureus, group B Streps, other Streptococcus sp., enterobacteriaceae & anaerobes

Antibiotic vary in how well they achieve effective concentration in the infected diabetic foot -- affected by the arterial blood supply to the foot & pharmacodynamic properties of the drug

DIABETIC FOOT INFECTIONS – INITIAL MEDICAL MANAGEMENT • The degree of end organ dysfunction affects multiple aspects of medical and surgical management • Antibiotic dosing adjustment issues, poor cardiac function, hyperglycaemia, ketoacidosis, dehydration, hyperosmolality, electrolyte imbalance, renal insufficiency, anaemia, poor limb perfusion, immunosuppression, poor nutrition, poor healing potential often coexist • The goal of medical management is to regulate and normalize the metabolic and haemodynamic derangements and to prevent further decompensations

STABILIZE / RESUSCITATE THE PATIENT • Restore fluid and electrolyte balances, correct anemia, hyperglycaemia, hyperosmolarity, acidosis & treat other exacerbating disorders

• Optimize treatment of other medical illnesses : ischaemic heart disease, heart failure, renal impairment etc • May need resuscitation eg sepsis, ketoacidosis

DETERMINE THE NEED FOR SURGERY When a non-healing infected diabetic foot ulcer is worsening despite adequate wound care and cultureddirected antibiotics, urgent surgery is needed Emergency surgical intervention : Life- or limb-threatening infection eg. Necrotising fasciitis Gas gangrene Critical limb ischaemia Deep abscess

OVERVIEW OF SURGICAL MANAGEMENT OF INFECTED DIABETIC FOOT To achieve a healed wound & prevent major amputation of the leg : • Darinage of pus, remove necrotic soft tissue & bone + creating a healthy wound bed • Limb reperfusion • Soft Tissue Cover

Incision & drainage Debridement Sequestrectomy Disarticulation Ray Amputation

SUCCESSFUL SALVAGE • Correct deformity, relieve pressure areas • Restore stability, alignment & function • Reduce risk of reulceration & subsequent amputation

DIABETIC FOOT INFECTIONS – INITIAL SURGICAL DEBRIDEMENT • • • • • • • • • • •

After patient is medically stabilised Must be timely and aggressive Remove all sloughs, necrotic and marginal-looking tissues, dead bones, drain all pus, explore all sinus tracts Exposed tendons should be excised if proximal migration of infection is suspected Exploration is done to determine involvement of fascial planes The degree of intra-operative bleeding must be assessed Aims to reduce the bacterial load in the wound, create a healthy environment to restore the physiologic processes of tissue repair and healing Changes stubborn non-healing chronic wounds into acute wounds Deep tissue & bone : C&S  HPE ( if osteomyelitis suspected) Crucial to successful control of infection and must be done as soon as possible In severe infections, general anaesthesia is often needed as the depth of infection and fascial spread may be extensive

ANTIBIOTICS THERAPY Based on culture & sensitivity results, depth and severity of infection CONTINUED UNTIL RESOLUTION OF INFECTION, NOT UNTIL THE WOUND HAS HEALED

OFTEN INSUFFICIENT WITHOUT APPROPRIATE WOUND CARE

TREAT THE INFECTION, DO NOT STERILISE THE WOUND

DIABETIC FOOT INFECTIONS --- WOUND BED PREPARATION • Converting a chronic wound into a wound with the potential to heal • Involves debridement, control of infection and inflammation, moisture control, excision of wound edges and callus • "TIME” - "T" refers to the need to remove necrotic and diseased Tissue - "I" indicates the need to control bacterial burden and Infection - "M" refers to restoration of Moisture balance - "E" stands for the healing Edge, which is the point at which the wound is optimally primed for healing

DIABETIC FOOT INFECTIONS --REPEATED SHARP DEBRIDEMENT • Repeated sharp debridement is done until all necrotic tissues and bone + biofilms are removed • Stimulates production of growth factors and proliferation of collagen and fibroblasts • A healthy wound bed is created for granulation tissue to grow and wound to heal

REPEATED DEBRIDEMENT - ULTRASONIC DEBRIDEMENT •

• •

•

Use of low frequency cavitational ultrasound to debride away dead tissues, leaving healthy and granulation tissue intact Also removes bacteria and biofilms Sterile saline solution transfer the ultrasonic energy to the wound where tiny vibrating gas bubbles and cellular level fluid movement separates dead from healthy tissues Safe, cost effective , painless alternative to painful sharp debridements Low-frequency ultrasound has been shown to have cellular-level physical effects, known as cavitation and microstreaming, that can promote healing Cavitation is the formation and oscillation of microscopic bubbles, which expand and collapse as they resonate with the ultrasound frequency Acoustic microstreaming is the physical force of sound pressure waves that can displace small molecules and move fluids along and/or through cell membranes.

REPEATED DEBRIDEMENT HYDROSURGICAL DEBRIDEMENT Versajet Hydrosurgery System ( Smith & Nephew) - utilises a high-pressure jet of sterile saline that travels parallel to the wound surface - This high-speed jet creates a Venturi effect that enables the surgeon to simultaneously hold, cut and remove tissue, while irrigating and aspirating the wound, with a single instrument • • • •

Enables rapid debridement, likely to result in shorter procedure times Clean wounds potentially reduce the number of required debridement procedures Single device technique - combining lavage and sharp debridement instrumentation Multiple tip configurations enhance procedural flexibility

REPEATED DEBRIDEMENT Maggots Debridement Therapy • • • • • • •

Sterile larva of the greenbottle fly is applied to the wound for 2-3 days Necrotic tissues are eaten away In late 1920s, William Baer from Johns Hopkins University, used maggots to treat children with osteomyelitis and soft tissue infections Successfully performed by thousands of physicians throughout 1930’s, but was supplanted by the new antibiotics and surgical techniques during World War II In 2004, FDA allowed the production and marketing of the Phaenicia sericata larvae In 2006, approx 50,000 treatments were applied to wounds using maggots Low cost, simple, safe, ideal when surgical debridement is not the optimal choice

REPEATED DEBRIDEMENT ENZYMATIC DEBRIDEMENT Involves application of a cream or ointment to the wound. The action of the chemicals or enzymes contained in the cream work to loosen the dead tissue, which is then manually removed Fast acting Minimal or no damage to healthy tissue with proper application. May be used as the primary technique for debridement in some cases when surgical debridement is not feasible owing to bleeding disorders or patient is not fit for surgery Combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent is effective for many patients with chronic, indolent, or nonhealing wounds

POST- DEBRIDEMENT SOFT TISSUE COVER • Presence of large soft tissue defect after surgical debridement often makes primary closure difficult • When possible, the least invasive methods of coverage are employed eg. Delayed primary closure Vacuum assisted closure • However, many wounds are not amenable to delayed primary closure and require plastic surgical techniques - Split Skin Graft - Local and Pedicle Flaps - Free Flaps

VACUUM ASSISTED CLOSURE Using a vacuum source to draw fluid out of the wound to accelerate debridement and promote healing Not for acutely ischaemic foot, tumour wound Special precaution : patient on anticoagulant Wound bed preparation prior to initiation of treatment Optimal level of negative pressure ~125mmHg Most effective if applied in a cyclical pattern – 5 mins on, 2 mins off Advantage : - cheap - Ideal for difficult- to heal wounds Disadvantages : - restricts patient mobility

DIABETIC FOOT INFECTIONS -- CELLULITIS • 9 times more frequent in diabetic compare to nondiabetic patients • Infection is confined to the dermal and subcutaneous layers • Commonly caused by Group A Streps & Staph • Entry : skin cracks, fissures, blister, insect bites • Antibiotics

DIABETIC FOOT INFECTIONS - OSTEOMYELITIS • A difficult problem to treat & heal • The combined effects of peripheral vascular disease, neuropathy, and repetitive trauma produce complex lesions with exposed bone, surrounding cellulitis, and soft tissue gangrene • Plain x-rays, gallium scan, MRI • Bone culture

DIABETIC FOOT INFECTIONS - OSTEOMYELITIS Diabetes Care August 2006 vol. 29 no. 8 1727-1732

A Clinico-microbiological Study of Diabetic Foot Ulcers in an Indian Tertiary Care Hospital Ravisekhar Gadepalli, MSC; Benu Dhawan, MD; Vishnubhatla Sreenivas, PHD; Arti Kapil, MD1; A.C. Ammini, MD; Rama Chaudhry, MD

All patients had Wagner 3-5 ulcers 62.5% had associated osteomyelitis

DIABETIC FOOT INFECTION - OSTEOMYELITIS • If osteomyelitis is confirmed from initial deep cultures or histopathology, further aggressive resection of all affected bone is warranted • DEBRIDE ALL DEAD BONE & SOFT TISSUE till viable, bleeding bone & soft tissue • Staph aureus penetrates and survives in bone cells * BONE PENETRATION OF ANTIBIOTICS * Fluoroquinolones ( ciprofloxacin, ofloxacin, moxifloxacin), Fucidic acid

NECROTISING FASCIITIS IN DIABETIC • • • • •

Incidence on the rise 70% of patients are diabetic MEDICAL & SURGICAL EMERGENCY ! Highly fatal ( overall morbidity & mortality : 70-80% ) Group A hemolytic streptococci ( Strep pyogenes ) and Staph aureus, alone or in synergism, are frequently the initiating infecting bacteria • However, other aerobic and anaerobic pathogens may be present, including Bacteroides, Clostridium, Peptostreptococcus, Enterobacteriaceae, coliforms, Proteus, Pseudomonas, and Klebsiella. • Poor prognostic factors : advanced age, poor glycaemic control, long duration of diabetes & delayed referral

NECROTISING FASCIITIS

• Progressive, rapidly spreading infection along the deep fascia plane & extensive necrosis of the subcutaneous tissues & muscle without a corresponding necrosis of the overlying skin until much later • Early features : Fever, pain, tachycardia, swelling, induration, cellulitis • Late features : Severe pain & tenderness disproportionate to skin changes, skin discolouration ( purplish black ), blister or bullae, crepitus, septicaemic shock, multiorgan failure • X-rays : subcutaneous gas • Antibiotics • Extensive surgical debridement & fasciotomy : delay for 24 hours  mortality

THE ISCHAEMIC DIABETIC FOOT UNLESS THERE IS ADEQUATE REPERFUSION OF THE FOOT / LEG, ANTIBIOTICS TREATMENT AND SURGERY WILL FAIL & AMPUTATION WILL BE NEEDED

SURGERY IN THE DIABETIC FOOT • Historically, diabetic foot surgery was largely done in the presence of acute infection or when in need of amputation

• With better understanding of the pathophysiology of diabetic foot disease, we have began to recognize the importance of elective diabetic foot surgery in helping patients to stay active and ulcer free

CLASSIFICATION OF SURGERY IN THE DIABETIC FOOT CLASS I ( Elective )

PURPOSE EXAMPLES For painful deformities in patients Realignment osteotomies, without neuropathy or open wounds tendon balancing procedures, II ( Prophylactic ) For prevention of ulceration in patients arthrodeses & Charcot with neuropathy but no open wounds reconstructions III ( Curative ) To assist healing of ulcers in patients Partial or complete removal of with neuropathy bone such as metatarsal head, sesamoid, accessory bone, exostosis, calcanectomy, soft tissue cover / reconstructions IV ( Emergent / To arrest / limit progression of acute Amputations, debridements, Ablative ) infection, eliminate infected and incision and drainage necrotic tissue

Armstrong DG, Lavery LA, Frykberg RG. Validation of a diabetic foot surgery classification. Int Wound J 2006;3(3): 240-246

ELECTIVE & PROPHYLACTIC SURGERY FOR THE DIABETIC FOOT GOALS : 1) Stability 2) Realignment 3) Platigrade foot amendable to bracing or accomodation 4) Reduction of pressure points / “surgical offloading”

ELECTIVE / PROPHYLACTIC SURGERY FOREFOOT : HALLUX and FIRST METATARSALPHALANGEAL JOINT : - SESAMOIDECTOMY / EXOSTECTOMY - HALLUX INTERPHALANGEAL ARTHROPLASTY / ARTHRODESIS

- RESECTION OF FIRST METATARSAL HEAD - OSTEOTOMIES OF THE PHALANX AND FIRST METATARSAL

LESSER DIGITS :

- LESSER METATARSAL OSTEOTOMIES : Shortening osteotomy Elevating osteotomy - LESSER METATARSAL HEAD RESECTION

ELECTIVE / PROPHYLACTIC SURGERY MIDFOOT : - EXOSTECTOMY - REALIGNMENT MIDFOOT OSTEOTOMIES + ARTHRODESIS - single plane vs multiplane

REARFOOT : - TRIPLE ARTHRODESIS

- REALIGNMENT CALCANEAL OSTEOTOMIES - TALECTOMY + TIBIAL-CALCANEAL ARTHRODESIS - CALCANECTOMY ( partial / total )

OPTIMIZE THE HOST Correct and reverse all correctable negative factors on wound healing : -

Anemia Diabetes Heart Failure Malnutrition Smoking Steroid Vitamin deficiency Uraemia

FORMULATE A WOUND CARE PLAN Optimal wound care is crucial for healing but it is not the only way to treat the diabetic foot ulcer Infection complicates treatment of a diabetic foot ulcer, making a more aggressive wound care strategy necessary One particular dressing should not be used for all stages of wound

• A long process – time, patience, perseverence -- Dedicated team of doctors and nurses

• Problems to be addressed in DFU : -- Exudate, bacterial load, slough, granulation

CHOOSING THE APPROPRIATE DRESSING  INFECTED : surgical debridement + silver dressing  EXUDATIVE : absorptive dressing eg. Hydrofibres, Alginates, Composite dressings, Foam dressings  SLOUGHY : surgical / enzymatic / maggot debridement  DRY : Hydrogels

SAVING EVERY LEG ? • Reducing the number of lower extremity amputations is a goal for all doctors caring for patients with diabetes • However, the numbers of limb-threatening infections continue to rise each year • Failures in limb salvage attempts do occur

• These failures result in multiple trips to the operating room, significant potential morbidity and prolonged disability

AMPUTATION

AMPUTATION

Somewhere in the world, a leg is lost to diabetes every 30 seconds Diabetics are 40x more likely to undergo amputation of the leg than non-diabetics >85 % of amputation begins with a foot ulcer

Those who undergo a lower limb amputation have up to 30% chance of undergoing similar amputation on the contralateral limb within 3 years and up to 50% chance in 5 years Mortality rate post amputation: 11-41% after 1 year 20-50% after 3 years 39-68% after 5 years

Two goals :

ABLATION + RECONSTRUCTION

“refashioned” the viable residual limb so that an appropriate prosthesis may be fitted to assist functional mobility

STRAUSS WOUND GRADING SCORE VARIABLES

2

1.5

PERFUSION DEPTH SIZE INFECTION WOUNDBASE

Warm Skin & sub-Q < thumb Clean & contam. Red

1

0.5

Cool Musc & tendons Thumb – fist Cellulitis Yellow-white

=8 0% amputation

0 Cold Bone & Joint >fist Septic Black

MINOR AMPUTATIONS : -

Disarticulation Ray amputation Midfoot amputation Syme amputation

MAJOR AMPUTATIONS : - Below knee amputation - Above knee amputation - Hip disarticulation

ENERGY CONSUMPTION AND AMPUTATION LEVEL AMPUTATION LEVEL

% ENERGY BEYOND BASELINE

Long BKA

10

Medium BKA

25

Short BKA

40

Bilateral medium BKA

41

Average AKA

65

Miller; Orthopaedic Review: Pg. 218.

AFTER AMPUTATION …….

CHALLENGE : PREVENTING RECURRENCE • •

Specialty diabetic foot clinic : recurrence rate 25-80%/year Self-monitoring - to identify signs of disease and precursors to injury - many diabetic patients with a high risk for ulceration cannot see their feet ! ( obesity, limited joint mobility, visual impairment ) - by the time patients in this study were able to visualize areas of concern, it was too late, and an ulceration had already developed • Self-care

CHALLENGE - PATIENTS EDUCATION & SUPPORT PERCEPTION & BEHAVIORAL CHANGE Overcoming : - Ignorance / Misconception - Fear - Denial - Uncooperativeness - Social problems

Increase awareness of : - DM & its many consequences - Methods of care & support available

CHALLENGE – THE OLD DIABETIC PATIENTS DIFFERENT FROM THE YOUNGER PATIENTS : • • • • • • • • • • •

Poorer limb perfusion Poorer healing / tissue regeneration Weaker immune defence Comorbidities ++ Soft tissue fragility / osteoporosis Poor nutrition Poor vision / memory / senility Limited mobility Social and financial support problems Dependant, poor self care, neglect NURSING HOME PROBLEMS

Two-thirds of elderly patients undergoing amputation do not return to independent life

CHALLENGE – HEALTHCARE PERSONNEL • Organisation : WOUND CARE TEAM - 70% of wound dressings are applied by the bedside nurse, NOT the wound care specialists

• Training ( Knowledge & Skills ) : - Train more people - Keep in touch with the latest development - Learn what to do, what not to do, how to do it

• Early detection & referral : - Educate & build a positive working relationaship with primary health care providers

• Budget & allocation

CHALLENGE – HEALTH CARE SYSTEM Although there have been many advances in the management of the diabetic foot, it remained a major global public health problem Where have we failed ? Health Care Policy ? Health Care Budgeting ? Health Care Organisation ? Policy Implementation ? What needs to be done ? Present ? Future ? What about the poorer countries and their people ?

CHALLENGE - RESEARCH FROM THE BENCH TO THE BEDSIDE - integration of resources into a coordinated effort and monitoring pathway to bring products of research and technology to the patients

FUTURE OF DIABETIC WOUND CARE • Narrowing gap between basic science and clinical application • Necessary to understand the complex interactions of various physiologic components in wound healing

• “SMART BIOACTIVE DRESSING” -- that responds to the needs of the wound by releasing factors needed for healing • “STEM CELLS” – as a potentiator of healing by replacing or activating senescent cells in the wound eg. Bioengineered skin

OVERALL MANAGEMENT • PREVENTION ! PREVENTION ! PREVENTION ! • Early detection and intervention • Medical management of diabetes and comorbid conditions • Targeted antibiotic coverage of infection • TEAM EFFORT • Wound care and dressing, off-loading / pressure relief • Adjuvant therapies (eg. Hyperbaric O2 ) & Nutrition • Post-op follow-up, podiatric care / foot wear and orthoses • PREVENT RECURRENCE !

THANK YOU

Doctor treating a foot ulcer : 17th Century, after David Teniers the younger